A nurse is collecting data from a client who is 24 hours postpartum.
Which of the following findings should the nurse expect?

Fundus firm, 4 fingerbreadths above the umbilicus

Fundus soft, 2 fingerbreadths below the umbilicus

Fundus soft, to the right of the umbilicus

Fundus firm, at 1 fingerbreadth below the umbilicus

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: A fundus that is firm and 4 fingerbreadths above the umbilicus 24 hours postpartum indicates uterine atony or retained placental fragments. This finding is not typical and may require further medical evaluation to prevent postpartum hemorrhage.

Choice B rationale: A soft fundus 2 fingerbreadths below the umbilicus suggests uterine atony, which can lead to postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract effectively after childbirth.

Choice C rationale: A soft fundus to the right of the umbilicus may indicate a full bladder pushing the uterus to one side. It can interfere with uterine contractions and should be addressed by encouraging the client to empty their bladder.

Choice D rationale: A firm fundus at 1 fingerbreadth below the umbilicus is the expected finding 24 hours postpartum. It indicates that the uterus is contracting well and returning to its pre-pregnancy size, reducing the risk of postpartum hemorrhage.

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Correct Answer is B

Explanation

Choice A rationale:

Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.

Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.

Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.

Choice D rationale:

Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after

A. You should place your nipple and some of the areola into her mouth B. Babies know instinctively exactly how much of the nipple to take into their mouth C. Your baby's mouth is rather small so she will only take part of the nipple D. Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth

Correct Answer is A

Explanation

Choice A rationale:

When breastfeeding, it’s important for the baby to latch onto not just the nipple, but also some of the areola, which is the

darker circle of skin around the nipple. This allows the baby to get a deep latch, which is necessary for effective breastfeeding.

The baby’s chin should be firmly touching the breast, and their mouth should be wide open. When they attach, you should see

much more of the darker nipple skin above the baby’s top lip than below their bottom lip.

Choice B rationale:

While it’s true that babies have certain instincts when it comes to breastfeeding, they still need guidance and proper

positioning to latch correctly. Simply relying on the baby’s instincts may not ensure a proper latch, which could lead to

ineffective breastfeeding and potential discomfort for the mother.

Choice C rationale:

The size of the baby’s mouth does not determine how much of the nipple they should take in. Regardless of the size of the

baby’s mouth, they should still latch onto the nipple and some of the areola for effective breastfeeding. Taking only part of the

nipple could lead to a shallow latch, which can cause nipple pain and may not allow the baby to get enough milk.

Choice D rationale:

While it’s important for the baby to take in a good amount of the breast tissue, including the nipple and areola, during

breastfeeding, suggesting to include some breast tissue beyond the areola might be excessive. The key is to ensure a deep

latch, which typically involves the nipple and some of the areola, rather than the entire areola and additional breast tissue.

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A nurse is collecting data from a client who is 24 hours postpartum. Which of the following findings should the nurse expect?

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A nurse is collecting data from a client who is 24 hours postpartum.
Which of the following findings should the nurse expect?